Participating in Expressions of
Addiction

In addition to enrolling participants through treatment
and education centers, we welcome interested parties to
participate in Expressions of Addiction. Do you have a
story to tell about addiction? Would you like your
photograph included in the project? Tell us your story and a little bit about yourself. For example, tell us
how has addiction affected you or those near you? Tell us
about your addiction or your recovery from addiction.

Please fill out the form below, or alternatively you can
print a copy of the
participant consent form and fax it to us at
1-781-306-8629.
Adobe Acrobat required for the printable
consent form.

Participant's Full Name

Date of Birth

Gender
Male
Female

Address

Address

City, State

Zip Code

Telephone Number

E-mail Address

Would you like us to use your real
name?
Yes
No

If no, what pseudonym should we use?

Tell us your comments
or how addiction has affected you or those near you: